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Trainee Information

Sex

Personal Information

Trainee grew up in (check all that apply)
Is there a history of?
Medications
Conditions
Check applicable boxes below

Physical

Autonomic
Migraines
Not a problemMust change
Irritable bowel
Not a problemMust change
Panic Attacks
Not a problemMust change
Allergies or asthma
Not a problemMust change
Tinnitus
Not a problemMust change
Cold hands/feet
Not a problemMust change
Dull chronic pains
Not a problemMust change
Tics/involuntary movements or vocalizations
Not a problemMust change
Tremors
Not a problemMust change
Experiences racing heartbeat
Not a problemMust change
Sharp shooting pains
Not a problemMust change
Fibromyalgia
Not a problemMust change
Chronically fatigued
Not a problemMust change
Hot flashes or chills
Not a problemMust change
Sensitivity to touch or light or sound
Not a problemMust change
Closes off to sensory awareness
Not a problemMust change
Does not like to be touched or held
Not a problemMust change
Sleep
Has trouble falling asleep
Not a problemMust change
Wakes often during the night
Not a problemMust change
Hard to awaken/never feel rested
Not a problemMust change
Wakes at night and can't sleep again
Not a problemMust change
Moves around a lot while sleeping
Not a problemMust change
Grinds teeth in sleep
Not a problemMust change
Wets the bed
Not a problemMust change
Sleep walks
Not a problemMust change
Nightmares or night terrors
Not a problemMust change
Night sweats
Not a problemMust change

Social

Social
Misses cues in social situations
Not a problemMust change
Difficulty forming or sustaining relationships
Not a problemMust change
Misses non-verbal meaning of communication
Not a problemMust change
Inability to feel others' emotions
Not a problemMust change
Needs to be the center of attention
Not a problemMust change
Does not accept authority
Not a problemMust change
Argumentative
Not a problemMust change
Inappropriate social interactions/behaviors
Not a problemMust change
Poor eye contact
Not a problemMust change

Issues related to mood

Stress
Overreacts to pressure
Not a problemMust change
Can't quiet the mind
Not a problemMust change
Speaks very fast
Not a problemMust change
Talks excessively
Not a problemMust change
Expects perfection of self/others
Not a problemMust change
Physically tense
Not a problemMust change
Speaks quietly or slowly
Not a problemMust change
Frequent tension headaches
Not a problemMust change
Anxiety
Often worried/anxious
Not a problemMust change
Relatively constant anxiety
Not a problemMust change
Tends to expect the worst
Not a problemMust change
Judges self negatively
Not a problemMust change
Shy or withdrawn in social situations
Not a problemMust change
Trembling/twitching/shakiness
Not a problemMust change
Feels on edge
Not a problemMust change
Easily startled
Not a problemMust change
Avoids places where he/she might be anxious
Not a problemMust change
Frequent thoughts of danger
Not a problemMust change
Sees self as unable to cope
Not a problemMust change
Thoughts of something terrible happening
Not a problemMust change
Depression
Energy levels are low
Not a problemMust change
Feels helpless or hopeless
Not a problemMust change
Cries easily
Not a problemMust change
Apathetic or indifferent
Not a problemMust change
Flat emotional response to positive events
Not a problemMust change
Seems lazy
Not a problemMust change
Weight loss or gain
Not a problemMust change
Decreased sexual desire
Not a problemMust change
Easily tired
Not a problemMust change
Trouble swallowing/lump in the throat
Not a problemMust change
Less interest or pleasure in usual activities
Not a problemMust change
Withdraws from or avoids people
Not a problemMust change
Finds it harder than usual to do things
Not a problemMust change
Sees self as worthless
Not a problemMust change
Difficulty making decisions
Not a problemMust change
Suicidal thoughts or plans
Not a problemMust change
Recurrent thoughts of death
Not a problemMust change
Low self esteem
Not a problemMust change
Self-critical thoughts
Not a problemMust change
Feels guilty or ashamed
Not a problemMust change
Anger
Has an explosive temper
Not a problemMust change
Explosive emotional reactions to minor events
Not a problemMust change
Irritable/impatient
Not a problemMust change
Reacts with physical violence
Not a problemMust change
Feels bitter/negative
Not a problemMust change
Anger outbursts after slow build-up
Not a problemMust change
Easily agitated
Not a problemMust change
Aggressive anger or irritability
Not a problemMust change
Outbursts of rage without cause
Not a problemMust change
Perceives events negatively
Not a problemMust change
Fear
Often afraid
Not a problemMust change
Paranoid thoughts
Not a problemMust change
Afraid in situations when others are not
Not a problemMust change

Issues related to cognition

Attention
Drifts off into thoughts when working
Not a problemMust change
Easily distracted from tasks
Not a problemMust change
Puts off starting assigned tasks
Not a problemMust change
Doesn't finish assigned tasks until the deadline
Not a problemMust change
Can't finish assigned tasks
Not a problemMust change
Difficulty completing tasks with multiple steps
Not a problemMust change
Works very slowly to be sure things are right
Not a problemMust change
Self-Control
Stubborn
Not a problemMust change
Acts/speaks impulsively
Not a problemMust change
Speaks quickly or loudly or interrupts
Not a problemMust change
Impatient/seeks stimulation/easily bored
Not a problemMust change
Tends to have quick emotional responses
Not a problemMust change
Fidgety/restless/hyperactive
Not a problemMust change
Handwriting is sloppy
Not a problemMust change
Tends to be clumsy/accident prone
Not a problemMust change
Can't control use of substances
Not a problemMust change
Driven to repetitive/compulsive behaviors
Not a problemMust change
Rigid thought; gets stuck on an idea
Not a problemMust change
Phobias or irrational fears
Not a problemMust change
Obsessive thoughts or fears
Not a problemMust change
Addictive behaviors
Not a problemMust change
Oppositional/defiant
Not a problemMust change
Dominant or demanding in relationships
Not a problemMust change
Argues frequently; doesn't give in
Not a problemMust change
Eating disorders
Not a problemMust change
Eats too little
Not a problemMust change
Eats too much
Not a problemMust change
Holds a grudge or dislikes change
Not a problemMust change
Self injury/cutting
Not a problemMust change
Pulls out hair
Not a problemMust change
Inappropriate sexual behavior
Not a problemMust change
Creativity
Concrete thinking
Not a problemMust change
Doesn't do well with tasks involving novelty
Not a problemMust change
Avoids creative tasks
Not a problemMust change
Doesn't enjoy fiction, arts
Not a problemMust change
Has difficulty seeing context
Not a problemMust change
Learning
Has a hard time listening for detail
Not a problemMust change
Has a hard time reading for detail
Not a problemMust change
Rushes tasks; makes silly mistakes
Not a problemMust change
Makes careless math errors
Not a problemMust change
Can't get math concepts
Not a problemMust change
Doesn't stay on track when speaking/writing
Not a problemMust change
Reverses letters/numbers
Not a problemMust change
Dyslexia
Not a problemMust change
Stutters
Not a problemMust change
Memory
Quickly forgets what is read/heard
Not a problemMust change
Quickly forgets tasks or learned material
Not a problemMust change
Can't remember past events
Not a problemMust change
Forgets faces/names
Not a problemMust change
Old memories keep intruding into thoughts
Not a problemMust change
Cannot recall periods of time from the past
Not a problemMust change
Thinking
Hyperfocuses or has difficulty changing tasks
Not a problemMust change
Difficulty balancing multiple tasks or assignments
Not a problemMust change
Highly detail oriented or structured
Not a problemMust change
Productive but gets worn down by workload
Not a problemMust change
Hears voices inside head
Not a problemMust change